Leave without Pay at Employee Share of Premium for Offline Agencies

Employees may not be placed on payroll for one day during a month to collect GIC deductions. If an employee is taking an approved leave of absence without pay due to one of these three conditions an application is required. Follow the procedures below:

Industrial Accident

Maternity

Personal Illness (employee’s illness only) Note: the employee is eligible to pay the employee's share of the premium if he or she has exhausted his/her sick and vacation time and an Application to Continue Part-Cost Premiums (Form-11) has been approved by the GIC.

To process these leaves:

Complete and Sign Employment Status Change Form (Form-1A) on behalf of the employee before the employee takes the leave without pay. Check off the appropriate Leave Type and indicate the start and end date of the leave and the last date on payroll.

Photocopy Employment Status Change Form (Form-1A) and file in the employee’s personnel file.

Send the original Insurance Employment Status Change Form (Form-1A) to the GIC.

You, the employee, the employee’s physician and the Agency Head must complete Application to Continue Part Cost Premiums (Form-11). In the case of a personal illness without pay, the employee must exhaust his/her vacation and sick time before Form-11 is submitted.

You or the employee sends the completed Form-11 and the Agency Head’s approval letter for the leave to the GIC.

The GIC will review the Form 11 and will notify the employee and the agency of the approval/denial.

Leave Without Pay – Approval Of Form-11

The GIC’s approval of a Form-11 will entitle the employee to pay the employee share of monthly premiums for his/her GIC coverage up to a maximum period of six months. The approval period is dependent on the employee’s illness, the agency’s approval period, and physician information. The GIC will direct bill the employee share of the premium.

If the employee does not return to work before the expiration date of the Form-11 approval, the employee must download from the GIC’s website and complete another Form-11 for renewal consideration. For renewals:

The employee, his/her physician, and the Agency Head complete a new Form 11.

You or the employee sends the completed Form-11 and a new Agency Head approval letter to the GIC.

You also complete a new Employment Status Change Form (Form-1A) on behalf of the employee. Indicate whether the leave is with or without pay, the leave type, the original leave start date and the new leave end date.

Photocopy all forms and file them in the employee’s personnel file.

Send the original forms to the GIC.

Leave Without Pay – Denials of Form-11

If the GIC disapproved the Form-11, the employee will be billed at the full cost premium. If the form is disapproved due to missing information, the employee has 21 days to resubmit the Form-11 with any missing items. If the employee does not return Form 11 with the missing items within the allotted time, the GIC will bill the employee at the full cost premium. Also, if the agency does not authorize or approve the leave, the GIC will bill the employee at the full cost premium.

LEAVE WITHOUT PAY AT FULL COST PREMIUM

If an employee takes an approved leave without pay for more than 30 days for the following reasons, the employee can continue GIC coverage by paying 100% of the premium. The GIC will direct bill the employee at his/her home:

Educational

Family leave to care for a dependent over age 3 (FMLA only allows part cost premiums for the first 12 weeks of the FMLA leave)

Sabbatical

Personal reasons

Employee suspension

To process these leaves:

Complete Employment Status Change Form (Form-1A) on behalf of the employee. Check off the appropriate Leave Type and indicate the leave start and leave end day and the last date on payroll.

Photocopy the Employment Status Change Form (Form-1A) and file it in the employee’s personnel file.